E-learning and E-modules in medical education—A SOAR analysis using perception of undergraduate students

Background Application of e-learning and e-modules in medical education has been shown to have a positive impact on learning outcomes among all types of learners, across diverse educational settings. Despite its benefits, e-learning and e-modules has not yet reached its full potential in medical education in India. Objective of this study is to evaluate the perception of undergraduate students regarding e-learning and e-modules using an appreciative inquiry tool SOAR (Strengths, Opportunities, Aspirations, Results) analysis, and to identify the barriers and challenges for the same. Methods This longitudinal study was conducted among participants from three consecutive batches (n = 250 x 3) of first-year medical students and two consecutive batches (n = 100 x 2) of first-year dental students. The sample was selected using a purposive sampling method. Two structured and validated questionnaires were developed for this study based on the modified Zhou’s Mixed Methods Model; the ‘Knowledge, Attitude and Practice’ Questionnaire (KAPQ) on e-learning and the feedback questionnaire (FBQ) on e-modules. The questionnaires were administered via MOODLE / hard copy, before and after the implementation of e-modules, respectively. Identified strengths, potential opportunities, probable aspirations and likely results for e-learning and e-modules were tabulated based on the qualitative analysis of perceptions of large number students sampled across three years. Results Six hundred and ninety students returned both questionnaires representing a response rate of 76.6%. Nine themes were identified in the “Strengths” domain as follows: Regular Update of Knowledge, Innovative Learning, Availability, Knowledge Sharing, Abundance of Information, Accessibility, Source of Knowledge, Creativity, and Increased Engagement. Eleven themes were identified in the “Opportunities” domain as follows: Clinical Skills training, Timesaving, Flexibility, Creativity, Increased engagement, Standardized content, Capacity building for students, Capacity building for faculty, Skills training, and Self-assessment. Thirteen themes were identified under the “Aspirations” domain with the three key themes being “maintaining and building on current strengths”, “increasing potential opportunities”, and “addressing the barriers and challenges identified in the responses to the KAPQ and FBQ questionnaire”. Four themes identified for ‘Barriers’ were eye strain, distractions, preference for conventional methodologies, and internet connectivity. Conclusions The findings of this qualitative study are based on the responses received from first-year medical and dental students of a Private University in Chennai, India. In this population of students, implementation of e-learning as blended learning using structured and interactive e-modules may provide more engagement during learning as well as support self-directed learning (SDL) directly or indirectly. Adoption of blended learning with e-modules as an integral part of curriculum planning may be beneficial for the achievement of Competency-Based Medical Education (CBME) goals in India.


Methods
This longitudinal study was conducted among participants from three consecutive batches (n = 250 x 3) of first-year medical students and two consecutive batches (n = 100 x 2) of first-year dental students. The sample was selected using a purposive sampling method. Two structured and validated questionnaires were developed for this study based on the modified Zhou's Mixed Methods Model; the 'Knowledge, Attitude and Practice' Questionnaire (KAPQ) on e-learning and the feedback questionnaire (FBQ) on e-modules. The questionnaires were administered via MOODLE / hard copy, before and after the implementation of e-modules, respectively. Identified strengths, potential opportunities, probable aspirations and likely results for e-learning and e-modules were tabulated based on the qualitative analysis of perceptions of large number students sampled across three years. a1111111111 a1111111111 a1111111111 a1111111111 a1111111111

Introduction
Training in medical education has been vastly influenced by technology and the e-revolution of the past 20 years [1,2]. E-learning, use of the internet and other related tools for learning, has become mainstream across the globe. Going beyond its broad characterization as online learning, Ellaway and Masters (2008) defined e-learning as "a pedagogical approach that typically aspires to be flexible, engaging and learner-centered; one that encourages interaction (staffstaff, staff-student, student-student), and collaboration and communication, often asynchronously (though not exclusively so)" [3]. E-learning is projected to continue to remain a key method of training delivery in health professional education (HPE) [4,5]. The role of e-learning in achieving the educational goals of HPE, especially in developing and under-developed countries has also been recognized by the WHO [6].
E-learning may be made more engaging and tailored to the delivery of formal education goals when supplemented with curricula-focused electronic lessons. E-modules are electronic lessons focusing on important learning concepts, built with a combination of teaching and assessment tools including text, images, audio, video, and gaming elements [7].
Application of e-learning and e-modules in medical education has been shown to have a positive impact on learning outcomes among all types of learners, across diverse educational settings [8,9].
Globally, many studies have documented the perceptions of medical students about e-learning. The overall consensus is that the acceptance rate of e-learning among medical students range from moderate to good. Many students have also indicated that additional digital training, superior designing of e-courses with enhanced interaction, and blending of traditional teaching with online methods would prove more beneficial [1,10,11]. However, in some countries, students did not favor e-learning [12]. These findings highlight the need to devise a strategic blueprint for e-learning implementation that meets the needs of students in a manner that is specific to each region.
Despite its benefits, e-learning has not yet reached its full potential in India. The Medical Council of India / National Medical Commission (MCI/NMC) advocated for innovative concepts including self-directed learning (SDL) and active teaching-learning methods as part of pedagogical strategies to deliver Competency-Based Medical Education (CBME) [13][14][15]. The capability of e-learning and digital tools to support SDL in formal education is well-established [16]. When used appropriately, e-modules are shown to persuade students toward lifelong learning [17]. It is, therefore, imperative to develop and implement an evidence-based road map for improving e-learning in medical education within the Indian context based on a careful assessment of the strengths, possible impact, and potential opportunities of this pedagogical approach.
SOAR (Strengths, Opportunities, Aspirations, Results) analysis is an appreciative inquiry tool that is uniquely tailored to enable strategic planning around well-defined goals [18]. SOAR analysis differs from the well-known SWOT (strengths, weaknesses, opportunities, and threats) analysis within two dimensions; it focuses on the future prospects and results from a subject of interest while SWOT aims at inherent weaknesses and perceived threats [19]. SOAR is guided by 'achieving the good' rather than 'avoiding an error'. SOAR is also driven by action, plan, and results [20]. Literature search shows lacunae in SOAR analysis specific to the Indian context that takes into account knowledge, attitude, and practice of e-learning among undergraduate medical students [14,15]. Hence, the present study was planned to study the perception of undergraduate medical students regarding e-modules during pre-covid times. Since elearning is projected to remain an integral part of medical education, the results can be used to improve e-module preparation and delivery for HPE as an integral curricula strategy.

Objective
To evaluate the perception of undergraduate medical students regarding e-learning and emodules using structured and validated questionnaires and SOAR analysis. A secondary objective of the study is to identify the barriers and challenges for the implementation of e-modules in undergraduate medical curricula in India, as perceived by undergraduate medical students.

Methods
Two structured and validated questionnaires were developed for this study based on the modified Zhou's Mixed Methods Model; the 'Knowledge, Attitude and Practice' Questionnaire (KAPQ) on e-learning and the feedback questionnaire (FBQ) on e-modules.

Item generation
Exhaustive literature review was carried out by authors to find existing validated questionnaires that were used in similar research settings. In addition, several informal focus group discussions were held with the head of the e-learning unit, phase one curriculum coordinator, educational experts and student representatives under the guidance of the Dean-Education, and Associate Dean of Education. The deliberations during the meetings were transcribed verbatim into a word document by secretaries. Experts in qualitative research performed thematic analysis on the captured data, resulting in the generation of themes that became the items on the KAP questionnaire (KAPQ) and feedback questionnaire (FBQ).

Data collection tools
The KAPQ comprised of 10 domains namely, general information (11 items), availability of computers & internet connectivity (6 items), purpose of using internet (6 items), self-reported confidence levels (10 items), preferred resources used for studying (6 items), preferred components of e-module (8 items), reasons for preferring e-learning (7 items), limitations of e-learning (11 items), and applications of e-learning in education (7 items). These were followed by three open-ended questions on major advantages, major disadvantages and the biggest challenge for e-learning in India [21]. The FBQ consisted of 14 items and four open-ended questions, on what students thought they 'liked the most', 'did not like', 'could have been done better', and 'suggestions for the improvement of e-modules'. To facilitate better understanding of the questions, the KAPQ and FBQ were constructed in simple English and scored on a fivepoint Likert Scale [22]. Relevance of the content, level of complexity of the language, sequence of items from simple to complex, and technique of administration of the questionnaires were taken into account when considering valid responses to the KAPQ and FBQ.

Validation
Face validity was carried out by three faculty who were not experts in e-learning.
To establish content validity, the questionnaires were examined by three internal and external experts based on the Lawshe method [23]. The experts belonged to a pool of faculty using e-learning for teaching and assessment, or medical educationists. Acceptance by five out of six experts was considered as a criterion for including the specified item in the KAPQ and FBQ. The validation exercises resulted in considerable modifications and improvement of the questionnaires.

Participants and procedures
Ethics Committee clearance was obtained from Institutional Ethics Committee (IEC-NI/12/ OCT/30/53) and written informed consent was obtained from all participants. The sample was selected based on the purposive sampling method. The data was collected from three consecutive batches (n = 250 x 3) of first-year MBBS students (2014-2017) and two consecutive batches (n = 100 x 2) of first-year BDS students (2015 to 2017). KAPQ and FBQ were administered to 900 students before and after implementation of e-modules respectively, through MOODLE / hard copy. 690 students returned both the questionnaires (response rate = 76.6%). The participant characteristics are shown in Table 1.

Data analysis
Collation of responses and descriptive data analysis was done across all the KAPQ and FBQ domains using SPSS version 17. The qualitative responses were then analyzed using thematic analysis [24]. A deductive approach was followed while interpreting the transcribed data and an inductive approach was utilized for recognizing patterns and generating themes [25]. The generated themes were examined carefully through a peer-review process to ensure internal similarity and external variability. SOAR analysis was performed on the findings. Fig 1 shows the overview of methodology. A pilot study was carried out for validating the questionnaire [26]. The quantitative responses of the present study were analyzed and published [27].

Strengths
Nine themes were identified under this domain follows: regular update of knowledge, innovative learning, availability, knowledge sharing, abundance of information, accessibility, source of knowledge, creativity, and increased engagement. Of the nine "strengths:, the two predominant themes under this domain were 'Accessibility' and 'Knowledge sharing'. E-modules are easily accessible; they are available even after the end of the lesson sessions and can be re-visited at any time. E-learning facilitates easy access to up-to-date knowledge in the medical field. Innovative learning and increased engagement were facilitated by the use of electronic tools such as videos and animations.

Opportunities
Eleven "opportunities" were identified in the raw data as follows: Clinical Skills training, Time saving, Flexibility, Creativity, Increased engagement, Standardized content, Capacity building for students, Capacity building for faculty, Skills training, and Self-assessment. The main themes under this domain were 'Creativity' and 'Increased engagement'. Creativity is an essential skill for medical workers that allows them to explain and convey clinical information in an effective manner to a recipient. Digital elements such as animations used in the e-modules were found to boost students' creativity. Use of visual aids and videos made learning more engaging compared to traditional methods of teaching such as lectures and seminars.

Aspirations
Thirteen themes emerged in the "aspirations" domain as follows: Dedicated IT personnel; Panel of educational experts for periodic content review; Increase students' engagement (illustrative videos, 3D images, interactive flash games, etc.); Hire a digital designer to work with educational experts; Standardize the e-learning process across universities; Provide official faculty development program on IT and multimedia; "Hours spent" metric and progress bar; Interactive games and visuals for clinical skills development; Forum discussion, post-test and self-assessment tests with personal leaderboard display), Streamline student enrollment; Emodules marks to be part of formative/summative evaluation, and Continuous development (periodic student/faculty feedback on content, technology, delivery, accessibility, quality, and other aspects that assess the quality of the e-learning experience). Of these aspiration themes, three key themes: maintaining and building on current strengths, increasing potential

PLOS ONE
opportunities, and addressing the barriers and challenges identified in the responses to the KAPQ questionnaire.
Maintaining and building on current strengths. Increasing students' confidence and comfort level with IT-based learning are imperative. These goals can be achieved by providing a tutorial at the beginning of the semester to introduce the students to the e-learning platform and walk them through how to access their e-modules and post-tests. Providing a dedicated IT personnel will allow for consistency in website maintenance and rapid resolution of any technical issues that may arise.
Increasing potential opportunities. Students' engagement and learning can be enhanced through the strategic use of illustrative videos and visual data in all e-learning modules. For example, interactive games and visuals can be introduced to guide students through technical and clinical procedures such as blood pressure measurement and minor surgery. The provision of discussion forums, post-test, and self-assessments may contribute to enhanced student learning.
Self-directed learning can be enhanced through the use of strategies such as "Hours spent" metric and "progress bar" that allows students to track how much time they spend learning online and how much they have completed so far.
Innovative techniques such as the introduction of a 'download' option that allows students to view pre-downloaded lectures and modules, while eliminating the need for a steady online connection in order to access lessons. Annual/periodic review of e-modules to be undertaken by a panel of educational experts assigned by the department head, to revise and update the information introduced in the e-modules as per approved educational curriculum and best-inclass/current evidence.
A list of resources such as websites that provide free-to-use visual aid material including 3D images geared towards medical content to be provided to teachers to support lesson creation.
A digital designer to be assigned to work closely with the lesson planning committee to create engaging e-module products based on the guidance provided by educational experts on the needed content.
Official faculty development programs geared towards the creation of effective online lessons, including technical details such as ensuring variability in voice tone to avoid monotoy, will support the effective delivery of e-learning.
Broader efforts to improve e-learning applications will include collaboration with other universities to exchange expertise and an attempt to standardize the e-learning process for medical education across universities.
Addressing barriers and challenges identified in the responses to the KAPQ questionnaire. All the barriers identified are mentioned under the 'barriers' section.

Results
In line with the anticipated continuation of e-learning as an integral pedagogical approach in medical education, all upcoming student batches would be enrolled in e-modules.
The progress and attainment of identified aspirations will be measured primarily using students' responses via periodic feedback questionnaires. Questionnaire domains would include content, technology, delivery, accessibility, and other aspects that indicate the quality of the elearning experience.
The target goal for students' confidence level in using IT-based learning tools is 99%. A student satisfaction rate of 90% and above on the e-learning experience would indicate a successful e-learning model. Periodic modifications may be made to the e-learning strategy based on feedback from students and faculty.
An increase in the total number of hours spent on the institution's e-learning platform is a positive indicator of utilization of the platform. The minimum engagement target is 85% for time spent on the e-learning platform and 100% for submissions of post-tests as a necessary requirement for passing a course.
Mapping of students' scores against their engagement levels will reveal students' progress as well as their confidence with technical skills.
An increase in the number of departments that offer online modules and an increase in the percentage of the curriculum content that is provided as an online module is a positive indicator toward adopting the hybrid learning method.
Receiving standardized and global accreditation would be a seal of achievement. Implementation of our model in other universities, following our guidance and recommendations, would denote the influence of our program ( Table 2).

Barriers
The four major themes that emerged under barriers and challenges to e-learning among undergraduate medical students in India were eye strain, distractions, preference for conventional methodologies, and internet connectivity. Online e-modules naturally increase the screen time spent in front of computers and mobile phones with the potential of leading to an increase in eye strain and other eye-related disorders. Distractions associated with e-modules include non-academic activities like playing games and social networking. Some students prefer conventional methods of learning such as using books and classroom lectures that allowed for the 'human element' to be present in learning. Lastly, although India is one of the biggest data consumers in the world, internet accessibility still remains limited especially in rural parts of the country. Other barriers identified in the study include the need for more creative elearning delivery (going beyond PowerPoint presentations), the threat to physical fitness associated with having online sessions at home, and low computer literacy among students.

Discussion
This study aimed at investigating the perceptions of undergraduate medical and dental students regarding e-learning / e-modules, and construct SOAR analysis based on the data collected. Administration of validated questionnaires based on the Knowledge, Attitude and Practices (KAP) model and the feedback questionnaire (FBQ) on e-modules allowed for access to students' opinion regarding the use of e-modules in medical education. Around two-thirds of the students preferred blended learning (BL), a combination of e-learning (EL) and face-toface (FTF) teaching, over absolute EL or FTF. They also held the view that EL should be viewed only as a supplement for traditional FTF teaching and not as a potential replacement for FTF. Many students perceived FTF teaching as providing an opportunity to interact with teachers, friends, and support staff. They felt that real-time verbal feedback was more meaningful and personal compared to digital feedback during EL. FTF also provides the opportunity for students to learn professionalism from observing their peers and teachers. However, FTF teaching was reported to be associated with limited teacher interaction during lecture classes. To overcome this challenge, some students recommended the use of smart boards and interactive digital tools during regular lectures, and interactive quizzes at the end of each lecture to keep students motivated and engaged.
Some students felt that e-learning saved them time, allowing them to spend more time on other life activities. Muthuprasad (2021) documented a similar finding that many students prefer e-learning because of its flexibility [25]. Some participants indicated that e-modules helped them have more control over their learning process and also facilitated self-directed learning. This perception is in alignment with the findings of Paechter & Maier (2010) [28]. Some students identified the distribution of well-structured and standardized content to all learners as one of the main strengths of e-learning. The role of e-learning in facilitating the acquisition of appropriate competencies was also identified. Similar findings are supported by other authors as well [28,29].
Conversely, some students identified eye strain, lack of human interaction, fall in motivation among students, low technology skills among faculty, coupled with non-engaging e-modules, as part of the current challenges for e-learning [28,30]. Addressing these barriers will lead to enhanced student motivation and enhanced e-learning implementation in the institution.
During this pandemic, many higher education institutions for health professional education embraced e-learning to ensure continuity of teaching [31][32][33]. However, the persistence of the pandemic has created a need for sustainable policies and pedagogical practices [34,35]. Some authors agree with the view that FTF sessions should be supplemented by a mix of asynchronous and synchronous online lessons which are content-rich and engaging [31,32]. It is, therefore, very likely that higher education during the post COVID era will be in a blended mode with the combination of FTF and online sessions [30,36].
The concept of readiness is important when designing, implementing, or assessing e-learning programs. Use of the KAP and FBQ aligned with determination of key attitudes that define readiness for e-learning in the literature. Organizational readiness refers to mental and physical preparation by the institution itself while readiness for e-learning among the medical students is based on the identification of predictors and barriers to e-learning [37][38][39]. Models of e-learning readiness in the literature identify two sets of variables: e-learning readiness variables (material and technological readiness, attitudinal readiness, mental health readiness, culture readiness) and inferential e-learning readiness [38,39]. The findings from this study aligned with the e-learning readiness variables of material and technological readiness and attitudinal readiness, and inferential e-learning readiness.
While the focus is on students' knowledge, attitude, and practice in regard to e-learning, faculty as individuals and teams collectively contribute to the success of any educational organization [20,36,37]. Hence, in addition to investing in digital infrastructure, the faculty has to be empowered to deliver blended learning (BL) through faculty development programs (FDP) [37]. Furthermore, continuous faculty development is a requisite for successful e-learning delivery [30,36]. Systematic planning coupled with streamlined implementation of e-learning strategies will improve the dependability of training delivery by the institution [37]. SOAR analysis is ideal for achieving this objective.
As a dialogue-based system, SOAR leverages generative dialogue, declarative statements, and opinions generated from the KAP and FBQ questionnaires to create a strategic plan for elearning in the research setting. Strengths in the context of this study refer to optimal use of elearning and e-modules in medical education as well as capacities and assets that allow optimal performance [18,20]; opportunities refer to situations and factors that may drive gains in elearning for students such as cross-disciplinary collaborations [20,40]; aspirations are visions and a long-term strategy that emerge from organizational strengths and capabilities, and results are outcomes from the execution of the strategy on e-learning and e-module [40]. An action plan for the use of e-module at the research setting emerged from the SOAR analysis.
There are four levels of activities in the action plan-infrastructural, student, faculty/institutional, and field levels. At the infrastructural level, the activities to be implemented are the creation of dedicated IT personnel and additions to technology infrastructure such as the introduction of a download option and various online educational tools identified to promote student learning.
At the institutional level, the activities to be implemented are creation of a panel of educational experts for periodic content review; engagement of a digital designer to work with educational experts; streamlining of student enrollment; and the implementation of continuous development programs (periodic student/faculty feedback on content, technology, delivery, accessibility, quality, and other aspects that assess the quality of the e-learning experience.
At the student level the activities to be implemented are increase students' engagement through the use of strategies such as illustrative videos, 3D images, interactive flash games, etc.; introduction of "Hours spent" metric and progress bar; introduction of interactive games and visuals for clinical skills development; implementation of forum discussion, post-test and selfassessment tests with personal leaderboard display, and e-modules marks to be part of formative/summative evaluation. The field level activities are standardization of the e-learning process across universities and the provision of official faculty development program on IT and multimedia.
The results from the SOAR analysis provide targets and metrics for evaluating these activities. Targets and progress indicators will be developed to align with each activity item. Targets and indicators for institutional level activities include periodic implementation of feedback, achieving increase in the department participation, and increase in curriculum delivery by hybrid learning method. Indicators for student-level activities include target of 90% satisfaction rate among students/faculty; target of 85% completion of e-modules; target of 100% submissions of post-tests; and results from mapping of students' scores with their engagement levels, confidence with IT skills, cognitive levels, learning style, etc. Targets for field-level activities include execution of progressive steps towards program standardization/global accreditation for e-learning in medical education and implementation of training programs for educators on e-learning.
The findings from this qualitative study are based on responses received from medical college students in a Private University in Chennai, India. The strengths of the study included the representative nature of the sample involving both genders across different cultures and socioeconomic status, and the study was conducted over a period of three years with three cohorts of students. The study was also conducted by Health Professionals who engage in both e-learning delivery and in medical education broadly. The limitations of the study include the small sample size (690) when compared to the size of the medical student population in India, the use of self-reported questionnaires (responses may be subject to personal bias), the use of a single institution limiting the generalizability of findings, 'hours spent' metric as mentioned in the study may not be a good indicator of learning. This study did not consider the views of the faculty, technical team, and leadership. Present study did not compare the scores after the introduction of e-learning modules, and therefore could not establish the correlation / association between e-learning and academic performance. Some of the important limitations of E-Learning that were not addressed in the study include 'limited opportunity to learn professionalism, need for academic integrity / self-discipline, endless distractions (home, workplace, online games, social media), inability to concentrate in isolation for long hours, superficial learning, and authenticity of the E-content' [41].

Conclusion
Development of structured and interactive e-modules in BL favors more engagement during learning and facilitates SDL. Implementation and management of BL with e-modules as an integral part of curriculum planning will promote CBME. A core team comprising of trained faculty, subject matter experts, qualified IT technicians, student representatives, secretaries, support staff, curriculum planners, assessment coordinators, quality assurance specialists, and educationists, will be necessary in order to achieve this goal. The findings from this SOAR analysis on the knowledge, attitude, practice, and feedback from a large sample of undergraduate medical and dental students may serve as a guide for institutions as they make strategic choices regarding BL.

Recommendations
• Effective use of blended learning methodologies will deliver a combination of cognitive and psychomotor competencies to students.
• The 'Flipped classroom' approach can be considered for better outcomes for BL • A core team of trained faculty, student volunteers, and qualified IT technicians may be crucial for development and validation of e-modules.
• Faculty development around e-learning technologies should be considered a high priority and receive prime attention.
• Online learning can be considered for formative assessment whereas FTF is ideal for summative assessments.
• Guidelines on 'online etiquette' for students and faculty should be made very clear during the beginning of the training program and emphasized throughout the program.
• It is advisable to have a stepwise strategic plan for establishment and sustainability of E-Learning infrastructure as it involves cost in terms of money, material and manpower.
Supporting information S1 Appendix. The supporting data for this article is provided as a supplementary file. (DOCX)